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Ann Thorac Surg 2008;85:1747-1751. doi:10.1016/j.athoracsur.2008.01.060
© 2008 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Endoscopic Thoracic Sympathectomy for Palmar Hyperhidrosis: A Randomized Control Trial Comparing T3 and T2-4 Ablation

Xu Li, MD, PhD*, Yuan-Rong Tu, MD, Min Lin, MD, Fan-Cai Lai, MD, Jian-Feng Chen, MD, Zhu-Jian Dai, MD

Department of Thoracic Surgery, First Affiliated Hospital, Fujian Medical University, Fuzhou, China

Accepted for publication January 18, 2008.

* Address correspondence to Dr Li, General Thoracic Surgery Department, First Affiliated Hospital, Fujian Medical University, Fuzhou City, 350005, China (Email: lixu1967{at}hotmail.com).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: Compensatory sweating is a major and troublesome complication noted frequently after sympathectomy in patients with primary palmar hyperhidrosis. This randomized clinical trial was projected to measure the impact of limited denervation on compensatory sweating while performing endoscopic thoracic sympthectomy.

Methods: Two hundred thirty-two patients with primary palmar hyperhidrosis were randomly allocated to either a T3 sympathectomy treatment, called group T3, or a T2–4 sympathetic treatment, called group T2–4. The patients underwent bilateral sympathetic ablation at corresponding levels. All patients were followed up and evaluated for comparison of symptom resolution, postoperative complication, levels of satisfaction, and severity of compensatory sweating between the two groups.

Results: Sex, age, family history, and distribution of sweating were similar in both groups. The postoperative complications were minor, and Horner's syndrome was not detected in either group. The frequency of mild and moderate compensatory sweating was not significantly different between the two groups, but the incidence of severe compensatory sweating was significantly lower after T3 sympathectomy (3% versus 10%). As for satisfaction rate, group T3 was superior to group T2–4 (96.6% versus 89.6%). The rate of symptom resolution was 100%, and no recurrence was found in either group.

Conclusions: The single-level sympathetic denervation under thoracoscopy is a safe and effective procedure to treat primary palmar hyperhidrosis. This method reduces the incidence of severe compensatory sweating postoperatively without compromising the patient's satisfaction.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Primary palmar hyperhidrosis is a condition marked by excessive perspiration beyond physiologic need, and is aggravated during periods of stress and anxiety. The excessive sweating often begins in childhood and is primarily of the upper extremities but may involve the plantar surfaces and axillae as well. The degree of sweating is variable, ranging in severity from moderate moisture to severe dripping. Epidemiologic survey [1] indicates that severe primary palmar hyperhidrosis was found in 0.37% of adolescents, which needs surgical intervention to gain permanent relief. An endoscopic thoracic sympathectomy (ETS) is now recognized as effective treatment for arrest severe hand sweating, and the development of an easy and safe video-assisted procedure has allowed for a rapid spread of its application. Despite impressive patient satisfaction rates with ETS, compensation sweating remains a most common and distressing complication. Although many efforts were made to minimize the incidence of compensatory sweating, the basic question of whether the specific level of sympathectomy influences the frequency and severity of compensatory sweating remains unanswered. The aim of this study is to compare the results of two different levels of denervation, T2–4 versus T3 only, in a prospective, randomized manner.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
Patients
During a 3-year period (June 2003 to June 2006), 428 patients were treated at our institution for primary palmar hyperhidrosis. All the patients received a detailed consultation to evaluate personal, professional, and social handicaps related to primary palmar hyperhidrosis. A preoperative chest computed tomography scan was performed to exclude lung or pleural disorder. Information about results and side effects of the procedure was given during this consultation. All patients were also assessed for the degree of symptoms [1] and distribution of excessive sweating.

Enrollment and Randomization
The trial was approved by the Ethics Committee of Fujian Medical University (No. 2003037). Prerandomization procedures for eligibility of patients consist of a careful evaluation of inclusion and exclusion criteria (Table 1) and collection of an informed consent. Additionally, a detailed medical history including demographic data and clinical status was documented. Randomization was performed following a computer-generated list. Patients were allocated to T2–4 denervation or T3 denervation by using sequentially numbered sealed envelopes with information disclosing the type of treatment to be applied. Recruitment began on June 2, 2003, and by the end of June 2006, a total of 232 patients had been randomly assigned, 115 patients to receive T2–4 denervation and 117 patients to receive T3 denervation.


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  		Table 1 Inclusion and Exclusion Criteria
 
Surgical Procedure
The bilateral sympathectomy in one stage was performed for all patients. The procedure was performed under general anesthesia using a double-lumen endotracheal tube. The patient was placed on the operating table in a semi-sitting position with arms in abduction. After clamping the right side of the tracheal tube, the thoracoscope (5-mm 0; Karl Storz GmbH & Co KG, Tuttlingen, Germany) was introduced through a 5.5-mm port in the right fifth intercostal space behind the border of the pectoralis major muscle. A second 5-mm port was introduced in the third intercostals space on the anterior axillary line. The sympathetic chain was identified at the level of the crossing of the second, third, and fourth costal heads. The parietal pleura was opened, and the target sympathetic chain was transected by diathermy. The incision was extended laterally for approximately 3 cm on the second or third costa to include any accessory nerve fibers (the nerve of Kuntz). All procedures were completed by insertion of a 16F chest tube through trocar, and the lung was reinflated under visual control. The chest tube was aspirated while the anesthesiologist ventilated the patient manually, exerting continuous positive pressure for a few seconds, to prevent pneumothorax before the drain was subsequently removed.

Follow-Up and Data Collection
All study patients were scheduled for follow-up either by visits or through the mail at 1 and 12 months after randomization. Patients were required to fill out a detailed questionnaire (Table 2). The data collected include resolution of symptoms, postoperative complications, the severity of compensatory sweating, levels of satisfaction with procedure, and incidence of symptom recurrence. The resolution of symptoms is a combination of completely dry and visible improvement.


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  		Table 2 Follow-Up Questionnaire
 
Statistical Analysis
All data were input into EPIDATA 3.02 and analyzed with SPSS for Windows 11.5 statistics program (SPSS, Chicago, Illinois). The differences between the two groups were calculated using the {chi}2 test. All p values less than 0.05 were considered statistically significant.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
The study group consisted of 232 patients, with a male:female ratio of 103:129. The data characterizing the patients are summarized in Table 3. The outcome of the operation is shown in Table 4. Our average operative time was 15 minutes. The time was calculated from the time of skin incision to the application of the dressing over the wound. This excluded anesthesia induction and reversal time. The average rise in probe temperature after nerve ablation was 2.1°C. It usually occurred 1 to 5 minutes after the ablation. No conversion to open technique was necessary, and there was no operative mortality. Although intraoperative bleeding was observed in 6 patients, none of them required hemostasis by open surgery. Fourteen patients were treated with a chest tube for postoperative pneumothorax. Horner's syndrome was zero in both study groups. Most patients were discharged on the first postoperative day (mean hospital stay, 1.2 days).


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  		Table 3 Patient Characteristics
 

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  		Table 4 Operative Details
 
One hundred and eighty-three patients (79%) returned the questionnaire immediately. Another 49 patients returned the questionnaire after a reminder or repeated mailing. Overall outcome after surgery is shown in Table 5. Patients who underwent a T3 sympathectomy were more satisfied than the patients who received T2–4 denervation (96.6% versus 89.6%, {chi}2 = 5.63 p < 0.05). Resolution rates of accompanying plantar and axillary hyperhidrosis were between 57% and 75% (Table 6), and there was no significant difference between the two groups. No recurrent symptoms were observed in our study.


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  		Table 5 Outcomes of Postoperative Follow-Up
 

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  		Table 6 Resolution of Symptoms
 
Table 7 shows the frequency and severity of compensatory sweating in the two groups. It was not significantly different between the two groups for mild or moderate compensatory sweating ({chi}2 = 1.40 p > 0.05 and {chi}2 = 0.32 p > 0.05). However, it is seen that severe compensatory sweating was significantly lower in group T3 ({chi}2 = 4.47 p < 0.05).


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  		Table 7 Compensatory Sweating
 

   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
Surgical treatment of primary palmar hyperhidrosis is based on interruption of transmission of impulses from sympathetic ganglia to eccrine sweat glands. Endoscopic thoracic sympathectomy is an effective, safe, and minimally invasive method for treatment of hyperhidrosis. The operative complication of ETS is relatively minor, but compensatory sweating remains as the most common side effect, which is negative factor for the postoperative results [2–5].

A variety of different surgical procedures have been used over time with varying results [2–9]. At present, there is no consensus for surgical procedure. The diversity of these surgical techniques focus on the following aspects: first, sympathectomy or sympathictomy (ie, resection or ablation); second, sympathetic ganglion denervation or sympathetic chain denervation; third, the extent of sympathetic denervation (ie, single-level denervation or multiple-level denervation); fourth, which level is the best level to ablate; and last, how to deal with Kuntz fiber.

The term "sympathectomy" historically referred to extirpation or destruction of the sympathetic ganglia and chain, and the term "sympathicotomy" meant severing the sympathetic chain. Modern day usage by the lay public has extended the term thoracic sympathectomy to include the latter operative technique as well because, from a functional perspective, the two technical approaches produce the same desired effects, that is, teh term "sympathectomy" is often used synonymously with "sympathicotomy." Comparing the two procedures, the mean operative time for a sympathicotomy has been shown to be significantly less than that of sympathectomy. Resection requires almost twice the time needed for ablation [10]. Furthermore, sympathicotomy is technically easier than sympathectomy, which is another important reason why the former is preferred in our study; although early in some experience, a standard three-port sympathectomy with resection of the sympathetic chain was employed. Nowadays, most studies [5–9] employ the sympathicotomy, allowing for fewer incisions and less external and internal tissue trauma, while producing equivalent clinical results.

When performing sympathectomy, some clinical series removed the sympathetic ganglion [4, 11]; others transected the sympathetic chain [7, 8]. As both procedures produced similar postoperative outcome, these studies placed little emphasis on the distinction between them. In our study, we prefer the "chain" ablation instead of "ganglion" transection, as the former is technically easier and causes fewer iatrogenic injuries. Many surgical anatomy studies [12, 13] also indicate that thoracic the ganglion was consistently located in the intercostals space, whereas the sympathetic chain lies against the corresponding costal head and is more superficial and visualized easier than ganglion. Other anatomical factors such as the superior intercostal vein are also considered as a cause of an unsuccessful procedure during ganglionectomy. Our clinical experience demonstrates that the arrangement of the right superior intercostal vein and its tributaries is more closely surgically relevant to the sympathetic ganglion than to the sympathetic chain. Injury to this vein may cause troublesome bleeding that compromises dissection of the sympathetic chain. In our series, simple ablation of the sympathetic chain at the corresponding costal head is preferable. The cautery transection is limited to that part of the nerve directly overlying the costal head, avoiding the intercostal space and its neurovascular structure.

Compensatory sweating is the most common and distressing complication for sympathectomy. It is characterized by the postoperative appearance of excessive perspiration in regions of the body where it had not been previously observed. Different studies have had controversial results in terms of this side effect [5–9]. The incidence of compensatory sweating depends on climatic conditions and emotional stress, and is higher in warm and humid locations. Compensatory sweating also will be greatly reduced as time goes by, and remains stable 6 months after surgery [5, 6]. At present, there is no consensus for the definition and classification of compensatory sweating. We defined severe compensatory sweating as follows: first, under the daily activity condition, the need to change underwear more than twice a day [14]; second, the timing of the diagnosis for compensatory sweating is 12 months after surgery.

The pathogenesis of compensatory sweating is obscure, and the proper procedure to resolve this problem has not been determined. It is postulated that this phenomenon is caused by a temperature-regulating compensatory mechanism in the body and is correlated with the extent of sypathectomy. That is, the greater the number of glands removed from thermoregulatory control, the greater is the response anticipated from the remaining glands. The main aim of our randomized clinical trial presented here was to find out whether there is an association between the extent of sympathectomy and the occurrence and severity of compensatory sweating. Our results revealed that the incidences of mild and moderate compensatory sweating in T3 and T2–4 sympathectomy were not significantly different, but severe compensatory sweating is signigicantly reduced in T3 sympathectomy (3% versus 10%). These results are similar to those of previous studies in which the authors reported a low incidence of compensatory sweating after T3 sympathectomy [7, 15].

Traditionally, the second thoracic ganglion is considered to be the key ganglion for sympathetic denervation of upper extremity [16]. In 2001, Lin and Telaranta [17] reported that compensatory sweating was less prevalent among patients who underwent T3 and T4 ganglion resection than among patients with T2 ganglion ablation. They theorized that the higher the interruption or resection in the sympathetic chain was performed, the more afferent fiber responsible for inhibiting sudoresis would be damaged, thereby causing a considerable increase in quantity and severity of compensatory sweating. After that, many studies [7–9, 11] have shown that preservation of the T2 ganglion may reduce the incidence of compensatory sweating. Presently, it seems that the T3 ganglion is the key ganglion for sympathetic denervation of the upper extremity, and ablation of the sympathetic chain at the third costal head is an optimum procedure for plamar hyperhidrosis.

Some authors [18, 19] have proposed that T4 sympathectomy or ramicotomy may decrease the incidence of compensatory sweating further. But in their study, the failure rate of symptom resolution was also increased. Our experience during sympathectomy procedures also indicates the T4 segment is not as important for sympathetic control of the hand as is T3. This is confirmed by lack of palmar skin temperature change after T4 ablation in some cases. Therefore, we recommend the carrying out of a prospective, randomized trial that compares T3 and T4 denervation in patients with palmar hyperhidrosis.

In our series, symptoms of palmar hyperhidrosis resolved in all patients without recurrence reported after 12 months of follow-up. The symptoms usually disappeared immediately after operation, and patients can confirm this in the recovery room. On the other hand, failure of symptom resolution can be attributable to various causes such as mistaken identification of the sympathetic level, incomplete ablation, or accessory nerve pathways (Kuntz fiber). An anatomic study [12] indicated that the accessory bypass nerve fiber directly connected the second or third or fourth ganglion to the brachial plexus. It was found in 34.9% (right) and 51.2% (left) of cadaver studies. When present, these fibers were a mean distance of 7.33 mm (range, 2.3 mm to 15.7 mm) lateral to the thoracic sympathetic chain. Therefore, in all sympathectomy procedures, we routinely extended the diathermy incision laterally for approximately 3 cm on the corresponding costa to include any accessory nerve fibers.

Complications were relatively rare and were minor in our series. The mean satisfaction rate was 93%, and no Horner's syndrome developed. Logically, the risk of developing Horner's syndrome could be expected to be lower in a very simplified sympathetic procedure. The interesting phenomenon of "rebound sweating" occurred in 3% of our patients. This obscure, transient excessive sweating of the target organ typically occurred on postoperative day 1 to 3, and lasted only about 1 day. The mechanism to explain this phenomenon is still not known.

In this randomized clinical trial, we endeavored to report the results of T3 and T2–4 thoracoscopic sympathectomy for treatment of primary palmar hyperhidrosis in one institution of Southeast China. From our results, we believe that simple T3 level sympathetic chain ablation is an optimum procedure for palmar hyperhidrosis. These findings could help us to reach a consensus on the standard operation for palmar hyperhidrosis surgery.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Tu YR, Li X, Lin M, et al. Epidemiological survey of primary palmar hyperhidrosis in adolescents in Fuzhou of People's Republic of China Eur J Cardiothorac Surg 2007;31:737-739.[Abstract/Free Full Text]
  2. Dewey TM, Herbert MA, Hill SL, Prince SL, Mack MJ. One-year follow-up after thoracoscopic sympathectomy for hyperhidrosis: outcomes and consequences Ann Thorac Surg 2006;81:1227-1233.[Abstract/Free Full Text]
  3. Doolabh N, Horswell S, Williams M, et al. Thoracoscopic sympatectomy for hyperhidrosis: indications and results Ann Thorac Surg 2004;77:410-414.[Abstract/Free Full Text]
  4. Dumont P, Denoyer A, Robin P. Long-term results of thoracoscopic sympathectomy for hyperhidrosis Ann Thorac Surg 2004;78:1801-1807.[Abstract/Free Full Text]
  5. Chiou TS. Chronological changes of postsympathectomy compensatory hyperhidrosis and recurrent sweating in patients with palmar hyperhidrosis J Neurosurg Spine 2005;2:151-154.[Medline]
  6. Schmidt J, Bechara FG, Altmeyer P, Zirngibl H. Endoscopic thoracic sympathectomy for severe hyperhidrosis: impact of restrictive denervation on compensatory sweating Ann Thorac Surg 2006;81:1048-1055.[Abstract/Free Full Text]
  7. Licht PB, Pilegaard HK. Severity of compensatory sweating after thoracoscopic sympathectomy Ann Thorac Surg 2004;78:427-431.[Abstract/Free Full Text]
  8. Katara AN, Domino JP, Cheah WK, So JB, Ning C, Lomanto D. Comparing T2 and T2-T3 ablation in thoracoscopic sympathectomy for palmar hyperhidrosis: a randomized control trial Surg Endosc 2007;21:1768-1771.[Medline]
  9. Kwong KF, Cooper LB, Bennett LA, Burrows W, Gamliel Z, Krasna MJ. Clinical experience in 397 consecutive thoracoscopic sympathectomies Ann Thorac Surg 2005;80:1063-1066.[Abstract/Free Full Text]
  10. Ueyama T, Ueyama K, Ueyama K, Matusmoto Y. Thoracoscopic sympathetic surgery for hand sweating Ann Thorac Cardiovasc Surg 2004;10:4-8.[Medline]
  11. Yazbek G, Wolosker N, Milanez de Compos JR, Kauffman P, Ishy A, Puech-Leao P. Plamar hyperhidrosis—which is the best level of denervation using video-assisted thoracoscopic sympathecotmy: T2 or T3 ganglion? J Vasc Surg 2005;42:281-285.[Medline]
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  14. Lai YT, Yang LH, Chio CC, Chen HH. Complications in patients with palmar hyperhidrosis treated with transthoracic endoscopic sympathectomy Neurosurgery 1997;41:110-115.[Medline]
  15. Gossot D, Toledo L, Fritsch S, Celerier M. Thoracoscopic sympathectomy for upper limb hyperhidrosis: looking for the right operation Ann Thorac Surg 1997;64:975-978.[Abstract/Free Full Text]
  16. Goetz RH, Marr JAS. The importance of the second thoracic ganglion for the sympathetic supply of the upper extremities—two new approaches for its removal Clin Proc 1944;3:102-114.
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  18. Choi BC, Lee YC, Sim SB. Treatment of palmar hyperhidrosis by endoscopic clipping of the upper part of the T4 sympathetic ganglion Clin Auton Res 2003;13:48-51.
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